Abstract and Introduction
Abstract
Purpose: To develop, teach, and supervise a structured process for handing off patient care and to evaluate its effect on interns' knowledge, skills, and attitudes toward handoffs.
Method: The authors developed a formal process for interns on the medicine ward services to hand off patient care at their teaching hospital. In July 2006, attending physicians began to teach and supervise the process. To evaluate the entire structured handoff program (the process, teaching, and supervision), interns were surveyed on the first day and during the last week of each of their month long rotations.
Results: From June through December 2006, the authors obtained 137 of 144 surveys (95% response) they had administered to 72 consecutive interns rotating through the hospital. During the first three months of the academic year, first-year interns had little confidence in their ability to hand off patients, make contingency plans, or perform read-backs when they began their rotations, but after exposure to the handoff program, their perceptions of these abilities increased (all P < .05). Eighty-five percent of the interns felt that attending supervision of the handoff process was useful or extremely useful, but only 51% viewed the lecture/small-group session about handoffs as useful.
Conclusions: The structured handoff program improved the participating interns' perceptions of their knowledge of the handoff process and their ability to transfer the care of their patients effectively. The formal program for teaching handoffs, that included attendings' supervision of the process, was well received.
Introduction
Communication failures are the most common root cause of sentinel events in U.S. hospitals. In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours in an effort to improve patient care and safety. Reduced duty hours have the effect of increasing the number of handoffs of patient responsibility, which can also increase discontinuity of care and worsen patient safety. Because poor sign-out practices have been directly linked to adverse events, the Joint Commission on Accreditation of Health Care Organizations requires that hospitals implement its new National Patient Safety Goal to improve communication between caregivers.
Although transfers of care are now increasingly frequent, as recently as three years ago, 60% of training programs had no formal process for teaching interns how to hand off patients. We suspect that, even now, few use comprehensive systems for conducting handoffs, generally leaving this task to unsupervised interns. With only 8% of U.S. medical schools formally teaching handoffs in a lecture/small-group session as of 2005, lack of adequate training in this increasingly important aspect of patient care is undoubtedly still prevalent.
In settings in which communication errors have high consequences (e.g., space shuttle mission control, nuclear power plants, railroad and ambulance dispatch centers), Patterson and colleagues found that handoff processes used verbal, face-to-face discussions that took place during periods when interruptions were limited. Handoffs also included the transmission of contingency plans with oncoming personnel actively participating in the process through interactive questioning. Health care systems have been slow to implement similar standardized, structured processes.
In July 2005, in response to ACGME duty hours regulations, the resident work schedule on the medicine teaching service at our teaching hospital was changed from an every-fifth-night call system with day floats to a shift system in which all housestaff worked defined shifts with fixed starting and stopping times. We recognized that this new system would result in more handoffs of care and that some of these handoffs would occur at times when patients still had numerous active issues. Accordingly, we also decided to improve handoffs by developing formal written and verbal (i.e., oral) templates as part of a highly structured process. By teaching how it should be done and by providing supervision, we attempted to ensure that patient-care handoffs were being conducted as designed. In the remainder of this report, we explain our new approach and report our evaluation of it to date.